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NEW QUESTION 20
A client experiencing delusions states, “I came here because there were people surrounding my house that wanted to take me away and use my body for science.” The best response by the nurse would be:
- A. “I know that must be frightening for you; let the staff know when you are having thoughts that trouble you.”
- B. “I need more information on why you think others want to use your body for science.”
- C. “Describe the people surrounding your house that want to take you away.”
- D. “There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science.”
(A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the client’s delusional system may force the client to defend it, and you cannot change the delusion through logic. (D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety.
NEW QUESTION 21
A group of nursing students at a local preschool day care center are going to screen each child’s fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?
- A. Revised Prescreening Developmental Questionnaire
- B. Goodenough Draw-a-Person Screening Test
- C. Caldwell Home Inventory
- D. Denver Development Screening Test
(A) The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. (B) The Goodenough Draw-a-Person test is used to assess intellectual development. (C) The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. (D) The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports.
NEW QUESTION 22
Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:
- A. Parkinsonism and dystonia
- B. Dystonia and akathisia
- C. Neuroleptic malignant syndrome
- D. Akathisia and parkinsonism
(A) Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements characteristic of parkinsonism. (B) Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of akathisia. (C) The client has symptoms of dystonia but not of parkinsonism. (D) The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism, obtundation, agitation, sweating, increased blood pressure and pulse.
NEW QUESTION 23
During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:
- A. Echolalia
- B. Akathisia
- C. Echopraxia
- D. Dyskinesia
(A) The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. (B) Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. (C) Echopraxia is mimicking the movements of another person. (D) Echolalia is mimicking the speech of another person.
NEW QUESTION 24
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. “I could stop taking this medication when I begin to feel better.”
- B. “I should always take this medication with an antacid.”
- C. “I should only take the medication if my heart rate is greater than 100 bpm.”
- D. “I would notify my physician immediately if I experience nausea, vomiting, and double vision.”
(A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. “Feeling better” indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin.
NEW QUESTION 25
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